Study Documents Large Variation in Heart Failure Care

Charlene Laino

November 10, 2003

Nov. 10, 2003 (Orlando) — Nearly one third of patients hospitalized for acutely decompensated heart failure who are candidates for treatment with angiotensin-converting enzyme (ACE) inhibitors are discharged without a prescription for the potentially lifesaving drugs, according to the results of the Acute Decompensated Heart Failure National Registry (ADHERE), the largest study of its kind.

The study, presented here Sunday at the American Heart Association Scientific Sessions, "documented large variations in heart failure care at the nation's hospitals," said chief investigator Gregg C. Fonarow, MD, the Eliot Corday Chair in Cardiovascular Medicine and Science at the University of California at Los Angeles.

"There are some hospitals where 100% of eligible patients get individualized treatment and counseling [at discharge] and others where patients had a better chance of winning the lottery," he said.

The phase IV observational open-label study showed that 32.2% of candidates for ACE inhibitors were discharged without receiving a prescription for the drugs; 71.6% were discharged without receiving a complete set of discharge instructions.

Also, 65.6% of current or recent smokers were not counseled on smoking cessation, and left ventricular function was not measured in 18.2% of patients, Dr. Fonarow reported.

All four measures are core quality-of-care indicators for the treatment of heart failure patients, according to the Joint Commission on Accreditation of Health Care Organizations (JCAHO). "The variation among hospitals regarding discharge instructions was staggering," Dr. Fonarow told Medscape. "All patients received instruction at five hospitals. But at one in four U.S. hospitals, not a single patient got complete discharge instructions."

Dr. Fonarow also noted that ACE inhibitor use varied considerably: "There were about 30 hospitals where all patients got prescriptions but 16 to 20 hospitals where none did," he said.

For the study, the researchers followed the first 54,639 patients enrolled in the ADHERE study, from its initiation in September 2001 through January 2003. Two hundred seventy-five acute care hospitals, caring for about 100,000 heart failure patients, now participate in ADHERE, the largest such registry, he said.

Patients in the study had a mean age of 72 years, 52% were female, and 59% had coronary artery disease. Average hospital stay was 4.5 days, and 4% died in the hospital.

So how could compliance with JCAHO performance standards be so dismal at some institutions?

"Many assume a colleague took care of it, but the most common response is, 'I don't know,' " Dr. Fonarow said.

The good news, he said, is that the hard data provided by the study will propel more physicians to conform to JCAHO standards.

"In the past, most physicians would have said they are doing these things," he said. "Just having this data is the first step toward changing things."

Richard Pasternak, MD, chief of preventive cardiology at Massachusetts General Hospital in Boston, agreed and said he believes physicians are already more likely to follow standard procedures than in the past.

"There is no single fix for improving quality of care," said Dr. Pasternak, who moderated a press conference at which the findings were discussed. "But things are getting better."

Kenneth A. LaBresh, MD, a clinical associate professor of medicine at Brown University in Providence, Rhode Island, said that the American Heart Association is discussing adopting its Get With the Guidelines program, already proven to improve quality-of-care performance among coronary artery disease patients, for heart failure patients.

The program uses an Internet-based patient management tool, collaborative learning sessions, teleconferences, and e-mail support to improve acute and secondary prevention carein patients with coronary artery disease.

"The same model would work well here too," Dr. LaBresh said.

In the meantime, hospitals participating in ADHERE have been given a customized tool called Optimize-HF that prompts physicians to offer heart failure patients standard care measures at admission and discharge, Dr. Fonarow said.

"If we don't have a checklist — with doctors, nurses, pharmacists and other healthcare workers reading it and rereading it — things get missed," he said.

The ADHERE registry is sponsored by Scios, Inc.

More information about ADHERE is available at

AHA 2003 Scientific Sessions: Abstract 2057. Presented Nov. 9, 2003.

Reviewed by Gary D. Vogin, MD